More trouble with statistics

Taking the big view how health care is paid for in the United States – private insurance, public plans, no insurance, some of each, we saw in the previous post that millions and millions of people have both public and private coverage and that tens and tens of millions have either public or private or no coverage at some point in time during any given year.

Think for instance of the veteran, eligible for VA benefits but also covered by an employer-sponsored private plan. Or a retired person with a private employer-based plan who turns 65 and enrolls in Medicare. Or a small business owner, with an individual private policy, who suffered a devastating accident, then couldn’t tend their business, then lost their savings and, at last unable to pay insurance premiums, must start the lengthy, sometimes humiliating process of applying for government disability benefits.

When it comes to health coverage there is more “churning” – movement between the uninsured, the insured and between public and private coverage – than we might expect.

Employers, over time, have tended to push the costs of coverage onto the employees, including withdrawing our health insurance as an offered benefit altogether, something that has been accelerating. So we can find ourselves uninsured while we look for a back-up plan – or switch plans, unexpectedly.

Changing jobs – even if both old and new jobs offer health insurance – likely means dis-enrolling from one plan and making it through a probationary period before another plan begins – a period when you are uninsured. For those laid off, COBRA is not enough and so being laid off usually means joining the uninsured.

In an “only in America” twist, people can lose their coverage by getting a new job or better job. If you qualify for Medicaid, in exchange for increasing your earnings you can be rewarded by becoming uninsured. This is a real phenomenon in an economy when many “new hires” have few benefits offered and jobs are so scarce – and can also undermine the ability of people with disabilities to seek employment.

I remember vividly a patient who suffered severe migraine headaches that gave her stroke-like symptoms. She and her husband, both working difficult jobs, made only a few dollars more per year more than they should. Neither job offered affordable insurance. And they we not eligible for Medicaid, but only because they made a few dollars, less than $100 over the whole year, more than the Medicaid-eligibility level.

Because of their meagre earnings and their dedication to their children, my patient went without medications or medical appointments. The day I met her she had been attending a course (that she paid for) that would allow her to qualify for a better job. But she collapsed in class only to be brought to the hospital – over her protests en-route. She didn’t want the ambulance bill, the ER visit bill, the hospital bill to compete with basic necessities for her children – and was willing to simply go home and lie down and hope that she recovered without diagnostic tests or treatments.

Speaking of one out of every four… more than one of every four of us has “government” coverage – Medicare, Medicaid, the VA, the IHS, Tricare and so on. What sense does it make to demand “get the government out of health care!” when so many millions have “government” health care? When we consider those with private AND public coverage it is not only more than one-quarter of us, but likely more than one-third of us in the “public” category – at least for some benefits, at least for some part of the year.

And then there are the uninsured. Families USA found that 86.7 million people were uninsured at some point in time during the two year period of 2007 and 2008. Not only is that is more than one out of every four of us – it is a heap of social insecurity in a time before unemployment hit double digits.

In the ongoing health debate we have heard again and again about “choice.” But when it comes to paying for health care in the United States, what choice do we really have? With premiums of a family policy above $14,000 per year, few (only about 4%) can afford to independently purchase health insurance. So we take the coverage for which we are eligible – through our employer, through the government, what have you – and a new job, a layoff, a serious illness changes our coverage, plenty of “churning” but little “choice.”

This is what the statistics above all reveal. No longer can the American people refer to the uninsured or those dependent upon government for health care as the people on the other side of the tracks. The trouble with the statistics is that “those people” are us! A single-payer national health program is the very smallest step forward we need to improve health care in the United States.